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CLINICAL PEDIATRIC DENTISTRY I 10

EARLY CHILDHOOD CARIES (DENTISTRY FOR THE CHILD AND ADOLESCENT, 8\ED

McDonald , Avery Dean, 2005; Chapter 10, pages 209-217 (only)

Tuesday 19\11\2013

1:00 pm-2:00 pm

OTHMAN AL-AJLOUNI 1

EARLY CHILDHOOD CAREIS ECC

Learner Objectives Upon completion of this presentation, participants will be able to:

1. Define caries and Early Childhood Caries (ECC).

2. Name the primary bacteria involved in the caries process.

3. Discuss the contribution of carbohydrate metabolism in caries

development.

4. State the important protective benefits of saliva.

5. List risk factors and describe the oral manifestations of ECC.

6. Describe the 5 stages of ECC and identify early lesions on physical

exam.

7. Discuss the impact of ECC on overall health and well-being.

8. Recall the 6 major methods of preventing ECC.

2

Etiology and Pathophysiology

There are 4 requirements for the formation of dental caries: 1. Bacteria 2. Sugar 3. Teeth 4. Time Because dental caries is an infectious process, caries cannot form in the absence of bacteria, regardless of sugar intake.

Bacteria adhere to the tooth surface in a biofilm called dental

plaque. When carbohydrates

are consumed, they are metabolized

by bacteria and produce acid as a

byproduct. The acid causes

demineralization of the tooth enamel.


The following factors contribute to demineralization: 1. High oral bacterial load 2. Frequent feedings 3. Poor oral hygiene 4. Decreased saliva production

These factors aid in the remineralization process: 1. Saliva 2. Good oral hygiene 3. A non-cariogenic diet

However, it is possible to reverse the demineralization process

before cavitation occurs.

Dental caries:

is a common chronic infectious transmissible

disease resulting from tooth-adherent specific

bacteria, primarily mutans streptococci (MS) that

metabolize sugars to produce acid which, over time,

demineralizes tooth structure.



Tooth decay is the single most common

chronic childhood disease

5 times more common than asthma

4 times more common than early

childhood obesity

20 times more common than

diabetes


Nursing bottle caries.

Baby bottle tooth decay.

Nursing bottle syndrome.

Rampant caries.


The disease of ECC is the presence

of one or more decayed (non-

cavitated or cavitated lesions),

missing (due to caries), or filled

tooth surfaces, in any primary tooth

of a child under the age 6 Years.

What is early childhood caries?


Severe early childhood caries (S- ECC) Is:

1. In children younger than 3 years of age, any sign of

smooth-surface caries is indicative of severe early childhood

caries (S-ECC).

What is severe early childhood caries?


2. From ages 3 through 5, 1 or more cavitated, missing (due

to caries), or filled smooth surfaces in primary maxillary

anterior teeth.

What are severe early childhood caries?


3. A decayed, missing, or filled score of dmft ≥4 (age 3).

4. dmft ≥5 (age 4).

5. dmft ≥6 (age 5).

What are severe early childhood caries?


There is early carious involvement of the maxillary anterior teeth, the maxillary and mandibular first primary molars, and sometimes the mandibular canines. The mandibular incisors are usually unaffected. A discussion with the parents often reveals an inappropriate feeding pattern: the child has been put to bed at afternoon naptime and/or at night with a nursing bottle holding milk or a sugar-containing beverage. The child falls asleep, and the liquid becomes pooled around the teeth (the lower anterior teeth tend to be protected by the tongue). It would seem that the carbohydrate-containing liquid provides an excellent culture medium for acidogenic microorganisms. Salivary flow is also decreased during sleep, and clearance of the liquid from the oral cavity is slowed.

BACTERIA The primary bacteria involved in the pathogenesis of caries is Streptococcus mutans, but many other bacteria have also been implicated, including S sobrinus, Actinomyces sp, and Lactobacillus sp. Increased numbers of bacteria increases a child’s risk for caries. The type of S mutans cannot be modified, but the number of bacteria can be altered.

These methods can be used to decrease bacteria and minimize caries:

1. Brushing

2. Flossing

3. Professional dental cleanings

4. Fluoride use

5. Chlorhexidine mouthrinses and Xylitol use

S MUTANS

S mutans is transmitted from the primary caregiver to infant by saliva.

Transmission rates increase when parents:

1. Share utensils or toothbrushes.

2. Taste food or drink before serving it.

3. “Clean” a dropped pacifier with saliva.

4. Allow a child to place fingers into an adult's

mouth.

SUGAR

Caries formation is promoted through the

following activities:

• Frequent or prolonged contact of the teeth

with sugary substances.

• Consumption of sticky foods.

• Dipping a pacifier in sweeteners like

honey or corn syrup.

• Regular use of medications that contain

sucrose, including some multi-vitamins.

saliva

Saliva has several important properties that help to

protect against caries:

• Saliva buffers acid.

• Saliva is bacteriostatic.

• Saliva aids in remineralizing the teeth.

• Decreased saliva production promotes

development of caries.

PRESENTATION AND TEETH AFFECTED ECC affects teeth that erupt first, those least protected by saliva, and those with grooved surfaces. ECC tends to affect the upper (maxillary) incisors first because they erupt earliest.

The primary molars are affected next because of their grooved surfaces.

Food easily becomes lodged in the molar’s pits and fissures, which are difficult areas to clean with a toothbrush.

The canines tend to be spared because they are smooth teeth that erupt later.

The lower teeth are better protected by

saliva and the tongue.

DIAGNOSIS AND STAGES

The stages of ECC are as follows: 1. Plaque: This biofilm contains cariogenic bacteria.

2. Incipient lesions or white spots: Usually begin along the gum line, which is the most important place to examine for ECC. With intervention at this stage, the caries process is entirely reversible.

3. Enamel caries: A defect in the enamel surface is visible.

4. Dentine caries: ECC has extended into the dentine layer, where the nerve and pain fibers are located.

5. Pulpitis: The infection has spread so that it now involves the pulp.

Risk Factors for ECC

Social/Environmental Characteristics: Ethnicity,

minority or low socioeconomic status, Parents with less than

a high school education, Limited or no dental insurance,

Limited or no access to dental care, Inadequate fluoride

exposure, Caries in a parent or sibling (especially in the past

12 months), High levels of S mutans in parents

Physical Characteristics: Children with special health care

conditions, Low birth weight (less than 2500 grams),

Gingivitis, Chronic conditions that weaken enamel, promote

gingivitis, or cause decreased saliva production, Visible

plaque on the teeth, Caries in the child

Behavioral Risk Factors: Poor nutritional/feeding habits,

Poor oral hygiene

PREVENTING ECC

Physicians who care for children Should teach the following

methods to prevent or delay caries:

1. Improve oral hygiene.

2. Alter feeding/eating practices.

3. Delay colonization of the teeth.

4. Ensure adequate fluoride.

5. Establish dental care, such as a dental home.

6. Use dental sealants.


- Is highly prevalent.

- Is largely untreated in children under age 3.

- High numbers of teeth affected.

- Consequences.

WHY IS THIS BABY SMILING?

She's smiling because she's happy! She is safe from

early childhood caries.

IMPACT AND EFFECTS ON HEALTH CONSEQUENCES:

1. Higher risk of new carious lesions in both dentitions.

2. Hospitalizations.

3. Emergency room visits.

4. Increased treatment costs.

5. Risk for delayed physical growth and development.

6. Loss of school days.

7. Increased days with restricted activity.

8. Diminished ability to learn.

9. Diminished oral health-related quality of life.

10. Destruction and loss of teeth

11. Damage to permanent teeth


Pain

Many cavities

Crooked permanent teeth

Ear and speech problems

Possible emotional problems

Early childhood caries may cause:


• Infectious

• Transmissible

• Diet Dependent

• Fluoride Mediated

• Reversible

acquisition of the caries-causing bacteria

Streptococcus mutans in children to occur through the

transmission of the bacteria from mother to child.


The following slides show the progression of Early

Childhood Caries.

Infectious

Transmissible

Diet Dependent

Fluoride Mediated

Reversible

Transmitted mainly from

mother or primary caregiver

to infant

Window of infectivity is first

2 years of life

Earlier child colonized, the

higher the risk of caries

Infectious/Transmissible

ECC Causes - Bacteria

Passed from caregiver to child food/drink

utensils

toothbrushes

Blowing on or

prechewing food

More likely if mother has

Decay Early spread increases

decay risk

Diet Dependent

• Caries is promoted by carbohydrates,

which break down to acid.

• Acid causes demineralization of enamel.

• Frequent snacking promotes 20 minute acid attacks.

• Foods with complex carbohydrates (breads, cereals,

pastas) are major sources of “hidden” sugars.

• High sugar content in sodas, Kool-aid, Hi-C, Snapple

etc.

ECC Causes - Diet

Food type

Starchy foods

Added or natural sugar

Pacifier dipped in sweetener

Liquid medicine

Feeding Habits that contribute to

ECC

• Bottles and sippy cups with fruit juice, soft drinks, powdered sweetened drinks, formula, or milk

• Sticky foods like raisins/fruit leather (roll-ups), and suckers

• Bottles at bedtime or nap time not containing water

• Dipping pacifier in sugary substances

ECC Causes - Time

Frequency and length of feeding

Bedtime bottle

“At will” nighttime nursing

“Carry along” bottle or no-spill training cup

Frequent snacking

Not Just What We Eat, But How

Often

• Acids produced by bacteria after sugar intake persist for 20 to 40 minutes.

• Number of times sugar is ingestion is more important than quantity.

AAP Recommendations for an

Oral Health Risk Assessment Assess mothers’/caregiver’s oral health.

Assess oral health risk of infants and children.

Assess child’s exposure to fluoride.

Recognize signs and symptoms of caries.

Provide anticipatory guidance including oral hygiene instructions (brush/floss).

Make timely referral to a dental home.

High-Risk Groups for ECC

• Children with special health care needs • Children from low socioeconomic • Children that lack topical or systemic fluoride

• Children with poor dietary and feeding habits

• Children whose caregivers and/or siblings

have caries

• Children with visible caries, white spots, plaque, or decay

Professionally Applied Topical

Fluorides (PATFs) Includes gels, foams, in office rinses and varnishes

• Safe, effective, easy to apply

• Promotes remineralization of enamel, arrest and/or reverse early caries

• Decreases enamel solubility

• Inhibits the growth of cariogenic

organisms, thus decreasing acid

production

Why recommend a fluoride varnish?

To prevent dental caries and in many cases reverse early dental caries

• Baby teeth are in a child’s mouth until about age 11 or 12

• No dental cleaning necessary prior to application

• No special equipment

• Quick, easy to apply (2 minutes)

• Sustainable service

How does the varnish work?

The lacquer-based product adheres to the dental enamel forming a depot

from which fluoride is slowly released

Making the tooth more resistant to acid dissolution

Saliva actually sets the varnish

Advantages fluoride varnish:

Easy to apply

Teeth do not need professional prophylaxis

Children can eat and drink following applications

Potential ingestion of fluoride is low

Prevents ECC

Q # 1

Through which of the following mechanisms does

saliva inhibit caries formation?

A. Supplying fluoride to aid in tooth remineralization.

B. Removal of dietary carbohydrates from tooth

surfaces.

C. Buffering of acid.

D. Providing calcium and phosphate to aid in

remineralizing the teeth.

E. All of the above.

Q # 2

The risk of caries development is directly

related to the frequency with which the

teeth are exposed to sugar.

A. True.

B. False.

Q # 3

Which of the following helps to prevent or

delay dental caries?

A. Limiting snacks between meals.

B. Ensuring adequate fluoride.

C. Improving oral hygiene.

D. Establishing a dental home.

E. All of the above.

Q # 4

Which teeth do Early Childhood Caries tend

to affect first?

A. Mandibular molars.

B. Maxillary incisors.

C. Mandibular incisors.

D. Maxillary molars.

E. All teeth are equally affected.

Q # 5

Which of the following bacteria is the primary pathogen

implicated in the development of dental caries?

A. Streptococcus salivarius.

B. Streptococcus mutans.

C. Bacteroides sp.

D. Streptococcus viridans.

E. Actinomyces sp.

THANKS FOR YOUR

KIND

ATTENTION

References

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November 20, 2006.

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8. Kaste LM et al. Coronal caries in the primary and permanent dentition of children and adolescents 1-17 years of age: United States, 1988-1991. J Dental Res. 1996; 75: 631-

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10. Lai PY et al. Enamel hypoplasia and dental caries in VLBW children: a case-controlled, longitudinal study. Pediatr Dent. 1997; 19(1): 42-9.

11. Lee JY et al. Examining the cost-effectiveness of early dental visits. Pediatr Dent. 2006; 28(2):102-5.

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Research, National Institutes of Health; 2000. Available online at http://www.nidcr.nih.gov/DataStatistics/ SurgeonGeneral. Accessed November 20, 2006.

15. Pettinato ES, Webb MD, Seale NS. A comparison of Medicaid reimbursement for non-definitive pediatric dental treatment in the emergency room versus periodic

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